[Long-term studies on the beta blocker talinolol (cordanum) with special reference to side effects]

224 patients with coronary heart disease, hypertension, disturbances of cardiac rhythm or hyperkinetic heart syndrome were treated with the cardioselective beta-blocker Talinolol (Cordanum) for a period up to 3 years. In 239 examinations in intravenous or peroral application of this medicament we controlled among others the appearance of side effects. This test was carried out with the help of standardised questionings and clinical controls. Apart from registrations of ECG and blood pressure clinico-chemical investigations were included and in the long-term experiment also tests by dermatologists, otorhinolaryngologists and ophthalmologists. In the total number of patients the proportion of side appearances was 17,6%, in the long-term experiment (100 patients with on an average 12.9 months) 7%. The symptoms most frequently cited in the initial phase, such as fatigue, weakness, insomnia and nausea receded within 4 weeks apart from few exceptions. There did not appear any essential bradycardic disturbances of the cardiac rhythm, just as little were references to disadvantageous reactions in the sense of a practolol syndrome.

Peripheral skin necrosis complicating beta-blockage

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Effect of nadolol in treatment of hypertension

Nadolol, a new beta-adrenergic blocking agent, was administered orally in gradually increasing single daily doses to 13 hospitalized patients with essential hypertension. Maximal doses ranged from 200 to 480 mg/day. Blood pressure was reduced in nine patients and heart rate was decreased in 11 patients. The decrease in blood pressure was either partial or temporary in five of the nine patients who responded. Concomitant administration of the diuretic chlorthalidone decreased blood pressure in a previously unresponsive patient. Nadolol effectively inhibited isoproterenol-induced tachycardia and decreased cardiac output by 18 per cent. Plasma renin activity and plasma aldosterone concentration were not changed significantly by the treatment. Body weight was not altered significantly. Blood pressure response was independent of the pretreatment renin levels or the change in renin induced by nadolol; it was also independent of the changes in cardiac output and heart rate but was more pronounced in patients with milder baseline hypertension. The decline in serum concentration of nadolol was consistent with the drug's reported half-life of 12.2 hours. The results indicate that single daily doses of nadolol alone can reduce blood pressure significantly with minimal cardiodepressant effects and no important side effects. The effectiveness of nadolol may be enhanced by the addition of a diuretic.

[Cholestatic hepatosis caused by Talinolol (Cordanum)?]

It is reported on a 38-year-old female patient who was treated for 18 days with 150 mg cordanum (talinolol) each and then fell ill with a dyspeptic clinical picture and signs of cholestase. The result of a liver biopsy was the picture of a cholestatic hepatosis. According to the results of the lymphocyte transformation test and the monocyte test as well as to the reexposition with following clinical recidivation the talinolol medication is to be regarded as cause. Pathogenetically is referred to the structural relations of talinolol to substances with paragroups as well as to a possible summation of different loads of the liver function.

Angina pectoris: effective therapy once daily

Twenty-nine anginal patients were randomly allocated to nadolol once daily, or propranolol four times daily and titrated to optimum dosage over 14 weeks under double-blind conditions: all patients then continued on nadolol once daily. Efficacy was assessed by numbers of anginal attacks and nitroglycerin (GTN) usage, and exercise EKG on the bicycle ergometer. Results showed the two drugs to have similar effects regarding anginal attacks and GTN consumption, but nadolol produced better performance in exercise time. In the extended treatment period on nadolol, the improvements over baseline readings were maintained. No serious side-effects or laboratory abnormalities were encountered.

Initial experience with a new long-acting beta-blocker, nadolol, in hypertensive patients

Nadolol, a new beta-blocker that is not metabolized and has a uniquely long pharmacological half-life (up to 24 hours) was employed as the sole drug therapy for thirty-one patients with mild to moderately severe essential hypertension. Twenty-two patients had a reduction over 3 months of 10% or more in supine diastolic pressure, including twelve who became normotensive. Daily dosage, administered in two divided doses, ranged up to 640 mg; however, twenty patients required 160 mg or less. Twenty-three patients continued therapy for a median additional period of 15 months, during which satisfactory control was maintained in seventeen patients. Side-effects of nadolol caused termination of therapy in only one patient.

Circulatory and metabolic effects of acute beta 1-blockade in severe pre-eclampsia

Five mg of a beta 1-adrenoceptor antagonist (atenolol) was given i.v. to 5 women with severe pre-eclampsia in the 3rd trimester of pregnancy. There was a significant decrease of both mean systolic blood pressure, from 171 to 155 mm Hg, and mean diastolic blood pressure, from 116 to 107 mm Hg. The mean maternal heart rate decreased significantly from 90 to 74 and mean fetal heart rate significantly from 145 to 138 beats per min. There were no significant changes in the plasma levels of cyclic AMP, insulin, glucose, free fatty acids, 3-hydroxy-butyrate or glycerol.

Comparative haemodynamic effects of labetalol, timolol, prazosin and the combination of tolamolol and prazosin

1 Four groups of patients with previously untreated essential hypertension in WHO stage I were treated either with timolol (n = 16), or prazosin (n = 13) or prazosin plus tolamolol (n = 12), or labetalol (n = 15).

2 Oxygen consumption, heart rate, cardiac output (Cardiogreen) and intraarterial brachial BP were recorded at rest in the supine and sitting position and during steady-state work at 50, 100 and 150 W before treatment and after 1 yr on drug therapy.

3 All regimes induced significant decrease in arterial BP at rest as well as during exercise.

4 BP reduction was achieved through different haemodynamic mechanisms. In the timolol group BP reduction was associated with a marked decrease in heart rate and cardiac output but no decrease in total peripheral resistance. In the prazosin group there was a significant decrease in total peripheral resistance at rest as well as during exercise. During exercise the cardiac index was higher than before treatment. In the groups treated with prazosin plus tolamolol or labetalol alone the changes were rather similar. There was a significant decrease in total peripheral resistance at rest, supine and during exercise. Heart rate was decreased, but much less than by the use of a pure β-blocker alone. Due to a compensatory increase in stroke volume, particularly during muscular exercise, the cardiac index was reduced much less than in the group treated with timolol.

5 The results indicate that the haemodynamic long-term effects of labetalol differ from those seen after long-term therapy on prazosin or β-adrenoceptor blockers and resemble those seen after combined treatment with both α- and β-adrenoceptor blockers.

6 The clinical significance of these differences is briefly discussed.

[Case report on a myocardial ischemia due to medical tocolysis with ritodrin (pre-par) (author's transl)]

In the 24 year old former competitive athelete tocolysis with ritodrin (pre-par) was started at 28 weeks gestation in her second pregnancy for premature labor. Diffuse cardiac ischemia occurred during the intravenous infusion of ritodrin. The betamimetic drug was the factor which started the myocardial ischemia as evidenced by the serial electrocardiograms. The importance of serial electrocardiograms during treatment with ritodrin is emphasized.

A double-blind study of the peripheral vasoconstrictor effects of the beta-blocking drug penbutolol in patients with Raynaud's phenomenon

A double-blind, placebo-controlled study was carried out in 10 hypertensive patients who were subject to frequent attacks of Raynaud's phenomenon and suffered from cold hands, to assess the peripheral vasoconstrictor effects of penbutolol. After a wash-out period of 2 weeks on placebo, patients received two 14-day treatment periods, in random order, with either 20 mg penbutolol twice daily or placebo separated by a second 2-week single-blind wash-out period on placebo. The results of digital blood flow measurements showed that penbutolol did not produce any additional vasoconstrictor effect on digital circulation. The significance of these findings is discussed.

Hemodynamic adjustments in hypertensive patients developing circulatory congestion during beta-adrenergic blockade

In the course of chronic treatment with a cardioselective beta-blocking agent (atenolol) 6 patients out of a series of 38 hypertensives developed signs of circulatory congestion. In spite of this, maximal exercise capacity was maintained. This resulted from hemodynamic readjustments at rest and exercise, where an increase in stroke volume played a major role.

A method for the measurement of tremor, and a comparison of the effects of tocolytic beta-mimetics

A method permitting measurement of finger tremor as a displacement-time curve is described, using a test system with simple amplitude calibration. The coordinates of the inversion points of the displacement-time curves were transferred through graphical input equipment to punched tape. By means of a computer program, periods and amplitudes of tremor oscillations were calculated and classified. The event frequency for each class of periods and amplitudes was determined. The actions of fenoterol-hydrobromide, ritodrin-HCl and placebo given to 10 healthy subjects by intravenous infusion in a double-blind crossover study were tested by this method. At therapeutic doses both substances raised the mean tremor amplitude to about three times the control level. At the same time, the mean period within each class of amplitudes shortened by 10--20 ms, whereas the mean periods calculated from all oscillations together did not change significantly. After the end of fenoterol-hydrobromide infusion, tremor amplitudes decreased significantly faster than those following ritodrin-HCl infusion.

[The harmful effects of beta2-sympathomimetic drugs as uterine relaxants on caesarean section (author's transl)]

Beta2-sympathomimetics are the most powerful inhibitors of uterine contraction used in order to prevent threatening fetal asphyxia. These drugs, however, can cause harmful interactions with anaesthetics during caesarean section. Our patient-material consists of parturients, who were given a beta2-sympathomimetic, ritodrine, immediately before caesarean section performed under combined general anaesthesia. These patients showed significantly more marked tachycardia, hypotonia and abundant haemorrhage during operation as a consequence of poor uterine contractility than did the control group. Rapid variations in the circulation of the mother may also be disadvantageous to the wellfare of the fetus. These side-effects can best be minimized by omitting atropine-premedication and by expanding the blood volume of the mother before caesarean section with adequate infusion of Ringer-type.

Beta-adrenergic blockade of the lung. Dose-dependent cardioselectivity of tolamolol in asthma

Beta-adrenergic blocking agents are widely used to treat disorders of cardiac rhythm and rate, angina, and hypertension. Propranolol is the most widely used beta-adrenergic blocking agent in this country. Because of its nonselective beta-adrenergic blocking effect, propranolol may be associated with significant bronchoconstriction in asthmatic subjects and in some patients with chronic obstructive pulmonary disease. Since tolamolol, a new beta-adrenergic blocking agent, has cardioselectivity in animals, we studied asthmatic subjects for six hours on three separate days in a double-blind crossover comparison of oral therapy with 40 mg of propranolol, its beta-adrenergic blocking equivalent dose of tolamolol (50 mg), and a high dose of tolamolol (100 mg). All three dosages had equipotent effects on heart rate and systolic pressure. The 50-mg dose of tolamolol had no effect on pulmonary function over six hours; however, both propranolol (40 mg) and the 100-mg dose of tolamolol had equivalent deleterious effects on airway resistance and on rates of expiratory flow. We conclude that the cardioselectivity of tolamolol is dose-limited but is present at the dosage of 50 mg, which is equivalent to the usual antiarrhythmic beta-adrenergic blocking dose of propranolol (40 mg).

Antihypertensive effect of trimepranol, a new beta-blocking agent

Trimepranol (TMP) is a new propranolol-like, non-selective beta-adrenoreceptor blocking drug. Its antihypertensive effect versus placebo was evaluated in a double-blind corss-over study in 25 ambulatory patients, whose supine diastolic blood pressure (BP) was at least 95 mm Hg. After four weeks treatment with placebo, the dose of TMP was titrated weekly until the supine diastolic BP was below 95 mm Hg or intolerable side effects occurred. The trimepranol dose thus determined was 10 mg bid for three patients, 20 mg bid for twelve patients and 40 mg bid for ten patients. The subsequent double-blind cross-over study consisted of two six weeks treatment periods, either with trimepranol followed by placebo (Group I) or in reverse order (Group II). BP and heart rate at the end of these periods were compared. Supine BP fell from 156 +/- 3/105 +/- 2 mm Hg at the end of placebo periods to 140 +/- 2/93 +/- 1 mm Hg (p less than 0.001) for systolic and diastolic BP at the end of trimepranol periods, when the data of Groups I and II are pooled. In 19 out of 25 patients, supine diastolic BP declined below 95 mmHg during the trimepranol period. A statistically significant correlation was found between the antihypertensive and bradycardic effects of trimepranol. Mild side effects occurred in the heart volumes of the patients. We conclude that bid trimepranol is an effective antihypertensive agent.

Comparative potency of intravenous penbutolol and propranolol in man

A study on the comparative potency of intravenously administered penbutolol, a new non-selective beta adrenoceptor antagonist, on the resting and post-exercise heart rate and rate-pressure product was carried out in 5 normal human subjects. The effects produced by 0.1, 0.2 and 0.3 mg of penbutolol and of 0.025 mg/kg (mean dose 1.28 mg) of propranolol was recorded. The dose of penbutolol producing an effect equivalent to that of propranolol was calculating from the log dose-response curve of penbutolol. In these tests, penbutolol was 7.90 and 7.66 times more potent than propranolol on a weight to weight basis. Penbutolol was well tolerated and no side-effects were observed.

Dose-ranging study of the new beta-adrenergic antagonist nadolol in the treatment of essential hypertension

A preliminary, single-blind, dose-ranging study was carried out in 30 patients with essential hypertension to assess the efficacy of nadolol, a new beta-adrenoceptor blocking agent without intrinsic sympathomimetic action and with an extremely long plasma half-life. After a 2-week period on placebo, patients were treated for 14 weeks with daily doses of 40 mg nadolol (20 mg twice daily). Dosage was increased every second week up to a maximum of 560 mg daily or until the patient was stabilized at an effective normotensive dose level. The results showed that at the end of the trial period there was a significant reduction in both systolic and diastolic blood pressure (approximately 34/21 mmHg) at an average daily dose of 110 mg nadolol. Apart from a tendency to bradycardia, explained by the drug's lack of sympathomimetic action, no other side-effects attributable to treatment were reported and no patient complained of sleep disturbance.

Beta-adrenergic receptor blocking drugs: tear lysozyme and immunological screening for adverse reaction

Patients who had received long-term therapy with practolol and other beta-adrenergic receptor blocking drugs were examined ophthalmologically. Tear lysozyme concentration and serum autoantibodies (antinuclear antibodies, DNA-binding antibodies and intercellular cement substance antibodies) were measured. It was found that beta-adrenergic receptor blocking drugs may have a pharmacological effect on the lachrymal glands, but this was not associated with dry eyes or adverse reaction. Practolol was found to be capable of reducing tear lysozyme concentrations to very low levels, and this was initially associated with high titres of ICC antibody. No other drug tested produced these effects.

The intraocular pressure response of glaucomatous eyes to topically applied bupranolol. A pilot study

Bupranolol 0.5% oily solution applied topically lowered intraocular pressure of glaucomatous eyes significantly. The pressure decrease is related to pretreatment pressure levels. The maximum effect occurred within 4 hours and lasted for more than 24 hours. No objective or subjective irritation could be attributed to the ophthalmic preparation. There was no significant effect on outflow facility, on blood pressure or tear flow. However, bupranolol produces local anesthesia on the eye. The problem of tachyphylaxis is discussed in the treatment of glaucoma with bupranolol eye drops.

Dose-titrated, double-blind, cross-over comparison of a selective beta-blocker and methyldopa in the treatment of hypertension

The efficacy and toxicity of tolamolol and methyldopa in hypertensive patients has been compared by a dose-titrated, double-blind, cross-over study. Thirteen patients completed the trial. Within the dose ranges investigated (tolamolol - 300 mg/day - 900 mg/day; methyldopa - 750 mg/day - 2250 mg/day)both drugs produced significant falls in laying and standing, systolic and diastolic blood pressures. Although the hypotensive effects of methyldopa were more marked than tolamolol, these only achieved conventional (P less than 0.05) levels of significance for lying blood pressure. There were no objective changes in haematological or biochemical indices during treatment with either drug, but patients complained of tiredness, weak limbs and mouth dryness significantly more during methyldopa treatment, than during either placebo or tolamolol therapy.

Antihypertensive effects of tolamolol

The antihypertensive and renin-lowering efficacy and side effects of tolamolol, a beta adrenergic blocking drug with cardioselectivity, were examined in 10 patients with mild essential hypertension while on regular diet. Tolamol, at a dose of 300 to 900 mg per day, given over a period of 2 to 4 wk significantly decreased systolic and diastolic blood pressures in both the recumbent and standing positions. Normal blood pressure (140/90 mm Hg or less) was attained in 8 subjects. Mean heart rate and ambulatory midday plasma renin activity (PRA) decreased significantly; however, there was no significant correlation between blood pressure decrease and either the pretreatment PRA or decrease in PRA. Body weight did not change significantly. No adverse side effects were detected and no changes in the liver or renal function or in the blood count were observed. It is concluded that tolamolol is effective in lowering blood pressure and PRA in patients with hypertension.

Efficacy of cardioselective beta adrenergic blockade with intravenously administered tolamolol in the treatment of cardiac arrhythmias

The efficacy of tolamolol, a cardioselective beta adrenergic blocking agent, was evaluated in the treatment of cardiac arrhythmias in 27 patients. Nineteen patients had supraventricular arrhythmias and eight had ventricular arrhythmias. Evaluation was by doulbe-blind randomized trial in 23 patients. Tolamolol was effective in reducing ventricular rate in 17 (85 percent) of 19 patients with supraventricular arrhythmias and resulted in conversion to sinus rhythm in 2 of the 17. The mean ventricular rate in 17 patients decreased from 135 to 102/min 10 minutes after initiation of administration of tolamolol and gradually decreased further to 93/min after 60 minutes. Reduction in ventricular rate was sustained for 2 hours of monitoring undergone by all patients and for 4 and 6 hours monitoring in two subgroups. Among the eight patients with ventricular ectopic beats, tolamolol reduced their frequency in four patients and had no effect in four. Six patients had chronic obstructive pulmonary disease and experienced no adverse clinical effects on respiratory function in association with administration to tolamolol. Untoward effects occurred in 10 patients, including hypotension in 3, 1 of whom required vasopressor therapy. Other side effects were sedation, nausea, dyspnea and warmth in the chest, all of which were mild and transient, requiring no treatment. Cardioselective beta adrenergic blockade with tolamolol was highly effective in controlling ventricular rate in supraventricular arrhythmias and reduced the frequency of ventricular ectopic beats in half of the small group of patients with this arrhythmia. It is particularly applicable in patients with obstructive pulmonary disease in whom cardiac beta adrenergic blockade is indicated. Hypotension is an important potential side effect.

Timolol maleate (Blocadren) in the treatment of essential hypertension

The antihypertensive activity of timolol (Blocadren, FROSST-MSD), a new beta blocking agent, was assessed in a single blind crossover placebo-controlled study in 14 patients with essential hypertension. Ten patients completed the trial. The average standing pressure during the placebos periods was 168/109mmHg and during the periods on treatment with timolol the average standing pressure was 139/92mmHg. All 10 patients showed some hypotensive response. The average daily dosage was 21 mg with a range of 15-30 mg. Four patients achieved optimal levels of blood pressure by the end of one week's therapy with the maximum time required being four weeks. Timolol appears to be an effective antihypertensive agent. Side effects were insignificant.

Long term treatment of moderate hypertension with penbutolol (Hoe 893d). I. Effects on blood pressure, pulse rate, catecholamines in blood and urine, plasma renin activity and urinary aldosterone under basal conditions and following exercise

The effects of penbutolol (Hoe 893 d), a new non-selective beta-receptor blocking agent, were studied in 5 patients with moderate hypertension. Initially, it was shown that 2-4 mg given orally once or twice daily tended to lower blood pressure and pulse rate, both at rest and following submaximal work. In prolonged trials (3-8 months) 4-60 mg/day were required to produce an acceptable antihypertensive effect. Penbutolol had no effect on the normal increase in plasma noradrenaline and adrenaline on standing, nor did it alter basal urinary catecholamine excretion. Submaximal work caused no significant change in plasma catecholamines before treatment, but there was a marked rise both in plasma noradrenaline and adrenaline during treatment with penbutolol. In short term studies there was a fall in plasma renin by 4 hours after oral administration of penbutolol 2-4 mg, which persisted for 24 hours. Prolonged treatment with penbutolol 20-30 mg twice daily inhibited renin production under basal conditions and following submaximal work, as well as lowered basal urinary aldosterone excretion. In one patient slight asthmatic symptoms appeared after treatment for 3 months with penbutolol. In other respects penbutolol was well tolerated.